[HAL-RAR for the treatment of hemorrhoids - a new, non invasive method]

Introduction: HAL-RAR is a new, minimally invasive technique for the treatment of haemorrhoids, whereby Doppler-guided ligation of the haemorrhoidal arteries (HAL) is combined with a mucopexy of the prolapsed haemorrhoidal tissue (RAR = Recto Anal Repair). Methods: We did these operations as an alternative to the conventional haemorrhoidectomies in the cases of grade III or - in some cases - grade II haemorrhoids. Between August 2017 and April 2019 a total of 45 patients were operated on with the HAL-RAR procedure. All operations were done under general or spinal anaesthesia. Results: Complications were seen in three patients within 30 days of surgery. One patient had proctitis, one patient suffered from a thrombosed haemorrhoid, while one patient had bleeding, which occurred on the 16th postoperative day. Two of them needed re-operation. Except one patient, all of them was treated in one-day surgery. HAL-RAR seems to be less painful than conventional procedures and causes more patient satisfaction in the early postoperative period. Neither the bleeding, nor the pain did not re-appear after 1 year, but one patient mentioned recurrence of the prolapse. Conclusion: Doppler-guided suturing is an effective, minimally invasive treatment option for even advanced haemorrhoidal diseases and seems to be ideal for one-day surgery.

Assessment of haemorrhoidal artery network using Doppler-guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications

BACKGROUND

Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries.

METHODS

All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations.

RESULTS

A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025).

CONCLUSIONS

The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.